So that is the crash that gave us CRM. The example illustrates the concepts in a powerful way.
It makes me remember a flight I had from San Francisco to Dulles where we were circling Dulles because of fog. We had two missed approaches at Dulles before diverting to Pittsburgh. I wonder what our fuel gauges were reading at Pitt when we landed.
I also had a case where someone was saved because of CRM. An extremely rare equipment failure occurred that required action within about a minute. However, the "symptoms" looked just like another condition that required a completely different intervention.
We did not solve the problem in a minute, but we methodically went through each possible cause, and everyone with an idea was heard until we found the answer. Each idea bought us a little time and kept fixation error from taking control.
Unfortunately, there is no required training in CRM in medicine. I only knew about it because I had recently written a short newsletter article about safety.
I think to strengthen this article I need to include an example that illustrates how things would have gone if medicine had standards / training similar to aviation that also illustrates all the ways we could have found the problem faster (simulation training), or avoided it completely (checklist). I need to see what sort of release I need to talk about this since we are restricted by HIPPA.
It seems like we would need to consolidate the rule making to go along with any new "penalty" / reward system. You cannot penalize someone for not following a bad rule.
We had a situation nationally where people were getting injured or killed because practitioners were disabling alarms. The ability to disable alarms was removed from monitors along with advisories not to do that. Then what happened was every time an anesthetic began, all the alarms would go off. It sounds crazy but that is what happened. It would be like every time you started down the runway to take off, bells ring all over the cockpit for no reason. Because there is no local or national feedback to "improve the rules", this went on for some time, and still it does happen.
Most people automatically put a 2 minute silence on the alarms in this situation because you cannot think with all these bells going off. You can't really fine people for that. If there was a feedback mechanism locally or nationally then the default settings on the alarms would be adjusted to something reasonable. Without the feedback people resort to the "work around".
So it seems we are missing feedback at all levels: (individual ~ CRM, local ~ ASAP, and national ~ ASRS /ASRP?) and a reward system that mitigates liability, plus rule maker consolidation so that properly vetted standards are introduced in practice, training, and equipment. All three components seem to be important.
For twelve years medicine has tried to see what "high reliability" interventions could be applied. Unfortunately, we have just scratched the surface. It is getting easier to see why there is no / minimal improvement. I hope I can paint a picture with words that makes it easy to understand.